Sunday, April 26, 2020

There is robust research to suggest that 70 to 80
percent of children with autism spectrum disorder (ASD) meet diagnostic criteria for one or more
co-occurring (comorbid) disorders and 40 to 50 percent meet criteria for two or
more. A Comorbid
disorder is defined as a condition that co-occurs with another diagnosis so
that both share a primary focus of clinical and educational attention. The most
prevalent comorbid conditions are anxiety, depression, attention-deficit/hyperactivity disorder (ADHD), disruptive behavior problems, and
chronic tic disorders, all which contribute to overall impairment.

Internalizing Problems

Studies have consistently
reported an association between ASD and internalizing symptoms, in particular,
anxiety and depression. A bidirectional association has been identified between
internalizing disorders and autistic symptoms. For example, both a higher
prevalence of anxiety disorders has been found in ASD and a higher rate of
autistic traits has been reported in youth with mood and anxiety disorders. Although
prevalence rates vary from 11% to 84%, most studies indicate that approximately
one-half of children with ASD meet criteria for at least one anxiety
disorder. Individuals with ASD also display more social anxiety symptoms compared to
typical individuals, even if these symptoms were clinically overlapping with
the characteristic social problems of ASD. In addition, there is some evidence
to suggest that adolescents and young adults with ASD show a higher prevalence
of bipolar disorders as compared to controls.

Depression is one of the
most common comorbid conditions observed in individuals with ASD, particularly
higher functioning youth. A study of psychiatric comorbidity in young adults
with ASD revealed that 70% had experienced at least one episode of major
depression and 50% reported recurrent major depression. Although another
documented association is with obsessive-compulsive disorder (OCD), it is
difficult to determine whether observed obsessive-repetitive behaviors are an
expression of a separate, comorbid OCD, or an integral part of the core
diagnostic features of ASD (i. e., restricted, repetitive patterns of behavior,
interests, or activities).

Externalizing Problems

An association between ASD
and attention-deficit/hyperactivity disorder (ADHD) and other externalizing
problems (i. e., oppositional defiant disorder) have been reported. Studies
have found that children with ASD in clinical settings present with
co-occurring symptoms of ADHD with rates ranging between 37% and 85%. Although
there continues to a debate about ADHD comorbidity in ASD, research, practice
and theoretical models suggest that co-occurrence between these conditions is
relevant and occurs frequently. For example, case studies suggest that ADHD is
a relatively common initial diagnosis in young children with ASD. It is also
important to note that a significant change in the DSM-5 is removal of the
DSM-IV-TR hierarchical rules prohibiting the concurrent diagnosis of ASD and
ADHD. When the criteria are met for both disorders, both diagnoses are given.

Other Comorbidities

Tourette Syndrome (TS) and
other tic disorders have been found to be a comorbid condition in many children
with ASD. A Swedish study showed that 20% of all school-age children with ASD
met the full criteria for TS. There also appears to be a higher incidence of
seizures in children with autism compared to the general population. The
comorbidity of ASD and psychotic disorders has received some research
attention. A study of children with ASD who were referred for psychotic
behavior and given a diagnosis of schizophrenia showed that when psychotic
behaviors were the presenting symptoms, depression and not schizophrenia, was
the likely diagnosis. Thus, individuals with ASD may present with
characteristics that could lead to a misdiagnosis of schizophrenia and other
psychotic disorders. Other co-occurring
conditions include physical(cerebral palsy, atypical gait), and
medical (allergies, asthma, gastrointestinal) conditions. Behavior
problems associated with GI distress may include sleep
disturbances, stereotypic or repetitive behaviors, self-injurious behaviors,
aggression, oppositional behavior, irritability or mood disturbances, and
tantrums. In addition, unusual responses to sensory stimuli, chronic sleepproblems, catatonia, and low muscle tone often occur in individuals with ASD. Specific learning difficulties are also common, as is
developmental coordination disorder.

Implications

Many individuals with ASD have symptoms that do
not form part of the diagnostic criteria for the disorder (about 70% of
individuals with ASD may have one comorbid disorder, and 40% may have two or
more comorbid conditions). The most common co-occurring
diagnoses are anxiety and depression, attention problems, and challenging behavior
disorders. When the criteria for a comorbid disorder is met,
both diagnoses should be given. Medical conditions commonly associated with ASD
should also be noted.The core symptoms of ASD can often mask the symptoms of a comorbid
condition. The challenge for practitioners is to determine if the
symptoms observed in ASD are part of the same dimension (i. e, the autism
spectrum) or whether they represent another condition. Although various
psychometric instruments, such as clinical interviews, self-report
questionnaires and checklists, are widely used to assist in diagnosis, these
tools are designed and standardized to identify symptoms in the general
population, and may not be appropriate and valid for use with ASD. Likewise,
their administration may be problematic in that individuals with ASD may have
difficulties in sustaining a reciprocal conversation, reporting events, and perspective taking. Nevertheless,
comorbid problems should be assessed whenever significant behavioral issues
(e.g., inattention, impulsivity, mood instability, anxiety, sleep disturbance,
aggression) become evident or when major changes in behavior are reported. Individuals who are
nonverbal or have language deficits, observable symptoms such as changes in sleeping
or eating or increases in challenging behavior should be evaluated for anxiety
and depression. Co-occurring conditions should also be carefully investigated when severe or
worsening symptoms are present that are not responding to intervention or
treatment.Further information on best practice guidelines for assessment and intervention is available from A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

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